Form 5500-PM-OG0010 "Application for Transfer of Well Permit or Registration" - Pennsylvania

What Is Form 5500-PM-OG0010?

This is a legal form that was released by the Pennsylvania Department of Environmental Protection - a government authority operating within Pennsylvania. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on September 1, 2006;
  • The latest edition provided by the Pennsylvania Department of Environmental Protection;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form 5500-PM-OG0010 by clicking the link below or browse more documents and templates provided by the Pennsylvania Department of Environmental Protection.

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Download Form 5500-PM-OG0010 "Application for Transfer of Well Permit or Registration" - Pennsylvania

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5500-PM-OG0010
Rev. 9/2006
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF ENVIRONMENTAL PROTECTION
OIL AND GAS MANAGEMENT PROGRAM
Application for Transfer of Well Permit or Registration
DEP USE ONLY
To identify wells to be transferred, fill out this form,
Client ID
Auth #
C.
INV.
naming the former operator and the new operator.
Please read instructions before starting. Use continued
APS #
Bond Agreement #
C.S.
ExA.
pages to list additional wells.
TRANSFER FROM:
TRANSFER TO:
Name
OGO#
Name
OGO#
Address
Address
City
State
Zip
City
State
Zip
Telephone
Fax
Telephone
Fax
Bond Number:
Bond Number:
SIGNATURES and CERTIFICATION
Subject to the penalties of Title 18-PA C.S. §4904 relating to unsworn falsification to authorities, I certify that I have the authority to submit this
request for transfer of permit or registration for the oil / gas wells listed herein. Further, I certify that the information provided on this form and
attachments is true and correct to the best of my knowledge and information.
SIGNATURE of Transferor, or Transferor’s authorized agent acting on
SIGNATURE of Transferee, or Transferee’s authorized agent acting on
behalf of the Transferor.
behalf of the Transferee.
Signature
Date
Signature
Date
(Type or print name and title)
(Type or print name and title)
WELLS TO BE TRANSFERRED
Permit/Reg #
D E P
County
Municipality
Farm Name
Well No.
Proj / Ser #
U S E
(Well API#)
Page 1 of
DEP USE ONLY
Approved by:
Regional Oil and Gas Manager
Date
This application is a request to transfer the permits or
registrations of
wells, the total of all pages.
- 1 -
5500-PM-OG0010
Rev. 9/2006
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF ENVIRONMENTAL PROTECTION
OIL AND GAS MANAGEMENT PROGRAM
Application for Transfer of Well Permit or Registration
DEP USE ONLY
To identify wells to be transferred, fill out this form,
Client ID
Auth #
C.
INV.
naming the former operator and the new operator.
Please read instructions before starting. Use continued
APS #
Bond Agreement #
C.S.
ExA.
pages to list additional wells.
TRANSFER FROM:
TRANSFER TO:
Name
OGO#
Name
OGO#
Address
Address
City
State
Zip
City
State
Zip
Telephone
Fax
Telephone
Fax
Bond Number:
Bond Number:
SIGNATURES and CERTIFICATION
Subject to the penalties of Title 18-PA C.S. §4904 relating to unsworn falsification to authorities, I certify that I have the authority to submit this
request for transfer of permit or registration for the oil / gas wells listed herein. Further, I certify that the information provided on this form and
attachments is true and correct to the best of my knowledge and information.
SIGNATURE of Transferor, or Transferor’s authorized agent acting on
SIGNATURE of Transferee, or Transferee’s authorized agent acting on
behalf of the Transferor.
behalf of the Transferee.
Signature
Date
Signature
Date
(Type or print name and title)
(Type or print name and title)
WELLS TO BE TRANSFERRED
Permit/Reg #
D E P
County
Municipality
Farm Name
Well No.
Proj / Ser #
U S E
(Well API#)
Page 1 of
DEP USE ONLY
Approved by:
Regional Oil and Gas Manager
Date
This application is a request to transfer the permits or
registrations of
wells, the total of all pages.
- 1 -
5500-PM-OG0010
Rev. 9/2006
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF ENVIRONMENTAL PROTECTION
OIL AND GAS MANAGEMENT PROGRAM
Application for Transfer of Well Permit or Registration
Use this page to continue the list of wells from previous page(s).
TRANSFER FROM:
TRANSFER TO:
Name
OGO#
Name
OGO#
WELLS TO BE TRANSFERRED
continued from previous page(s)
Permit/Reg #
D E P
County
Municipality
Farm Name
Well No.
Proj / Ser #
U S E
(Well API#)
Initial (DEP
Page
of
DEP USE ONLY:
R.P.M. or other)
- 2 -
5500-PM-OG0010
Rev. 9/2006
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF ENVIRONMENTAL PROTECTION
OIL AND GAS MANAGEMENT PROGRAM
Application for Transfer of Well Permit or Registration
INSTRUCTIONS
GENERAL
SIGNATURES
Use Page 1 for the first 15 wells; and the continued page to list
The new operator or authorized agent must sign the transfer
additional wells. Clearly number each page at the bottom left, for
form.
The former operator should sign the form to indicate
example, as “Page 3 of 7”. On Page 1 under the page number,
consent to the transfer, except where the former operator is
clearly type or print the number of wells included in this application
unavailable or incapable.
If it is not possible for the former
for transfer.
Applications with pages not clearly numbered or
operator (or agent, attorney, or executor) to sign the application,
lacking a total count of wells may be delayed.
the new operator’s signature will be sufficient.
In that case,
please submit a statement explaining why the former operator is
unavailable to sign the form.
BONDING THE WELLS
If the well operator is an individual, either doing business in his
The new operator’s bond must be in effect before the transfer will
own name or under a fictitious name (registered or not), he must
be approved for wells that must be bonded. Wells drilled before
sign his own name.
April 18, 1985 (the effective date of the Oil and Gas Act) are
exempt from bonding requirements.
Individuals in joint ownership must authorize one person to sign
on behalf of all, or all joint owners must sign this form. Attach the
A new owner or operator who is acquiring only bond-exempt wells
authorizing resolution.
must complete and send in an Operator’s General Information
Form (5500-FM-OG0099) along with the application for transfer
Unincorporated business entitites using a fictitious business
form. No bond documents would be required.
name must have the name registered with the Pennsylvania
Department of State. Only individuals duly authorized by the
A new well owner or operator who must post a bond must submit
owners of such a business may sign this transfer form.
appropriate bond documents for approval, along with an Oil and
Gas Operator's General Information Form (5500-FM-OG0099)
If the well operator is a partnership, the transfer form must be
and the Application for Transfer of Well Permit or Registration.
signed by all partners or an authorized general partner. Attach
the authorizing resolution.
Use additional blank paper for
An operator with an approved bond on file with the Department
signatures if needed.
must submit a transfer form and a Bond Exhibit A form (5500-FM-
OGO0042) listing the wells that are required to be bonded (that is,
If the well operator is a corporation, the transfer must be signed
those drilled after April 17, 1985).
by an authorized corporate officer.
Attach the authorizing
resolution.
The operator’s name on bond documents must be exactly the
same as it appears on this transfer form.
A well operator may empower a person by specific power-of-
attorney to sign on behalf of the operator. The signature of that
REMINDERS
person on file with the Department is acceptable.
A well owner or operator is required by law to notify DEP in writing
Names and titles must be printed or typed under each signature.
within 30 days of acquiring an oil or gas well by purchase or other
Words crossed-out and other corrections must be initialed and
conveyance (see 25 Pa. Code §78.14(a)). The transferor (old
dated by all parties signing this form.
operator) is held liable for the wells until DEP approves the
transfer of responsibilty.
NOTICE
Approval by DEP of an application to transfer a well permit or registration does not confer property rights. The
Department’s approval only recognizes the transfer of authority under the Oil and Gas Act to operate the well and
the responsibility for plugging the well upon abandonment.
Send your completed form with all related
Dept. of Environmental Protection
Dept. of Environmental Protection
attachments to the proper DEP regional
NW Regional Office – Oil & Gas
SW Regional Office – Oil & Gas
office. If you have any questions or need
230 Chestnut Street
400 Waterfront Drive
more forms or information, contact the bond
Meadville, PA 16335-3481
Pittsburgh, PA 15222-4745
clerk in the regional office.
Phone: 814-332-6860
Phone: 412-442-4024
Fax: 814-332-6121
Fax: 412-442-4328
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